Bifrontal Decompressive Craniotomy in a 6-Month-Old Infant with Posttraumatic Refractory Intracranial Hypertension

Abstract

Objective: To document the outcome of bifrontal decompressive craniotomy (BDC) in an infant who developed refractory intracranial hypertension (IH) and massive brain infarction following severe head injury. Clinical Presentation: A 6-month-old girl sustained a severe closed head injury in a car accident. Her Glasgow coma score dropped from 10 to 6/15 within 6 h after admission, and her pupils became dilated and fixed. CT brain scans showed severe brain swelling and extensive infarction in both cerebral hemispheres with no grey-white mater differentiation. She developed a state of refractory IH despite maximal medical treatment. Intervention: She hadBDC and duraplasty carried out 8 h after admission. She made a quick recovery to Glasgow outcome score 3, and her total hospital stay was 10 weeks. Conclusion: BDC can be a life-saving procedure for infants with refractory IH and massive brain infarction.

Decompressive craniectomy in a three-month-old infant

“…Decompressive hemicraniectomy and duraplasty can relieve the pressure from swollen, infarcted brain tissue thus preventing brain herniation and death in patients with refractory intracranial hypertension due to various etiologies in adults 1e3 as well as in children. 4,5 A three-month-old male child presented to the emergency department about 10 h after with the fall from his mother's lap (about 4 feet height). Since then the child was in altered sensorium and had multiple episodes of vomiting.…”

“…5,7,8 According to the guidelines, indications for decompressive craniotomy in children with traumatic brain injury include medically refractory intracranial hypertension, diffuse cerebral swelling on cranial CT imaging, admission to the hospital within 48 h of injury, no episodes of sustained ICP > 40 mm Hg before surgery, GCS > 3 at some point subsequent to injury, secondary clinical deterioration, and if there is evolving cerebral herniation syndrome. 5,9 The decision to perform surgical decompression is based primarily on clinical findings of bulging and tense fontanel, secondary clinical deterioration due to cerebral herniation (mydriasis and anisocoria) and the radiological findings of severe brain swelling causing obliteration of the basal cisterns however the procedure should ideally be carried out before the evolution of brain infarction and secondary brain damage. 5 There are many issues that need to be clarified including the size of craniotomy (particularly when the fontanels are not fused), also material and timing of craniolpasty in these patients.…”

“…5,9 The decision to perform surgical decompression is based primarily on clinical findings of bulging and tense fontanel, secondary clinical deterioration due to cerebral herniation (mydriasis and anisocoria) and the radiological findings of severe brain swelling causing obliteration of the basal cisterns however the procedure should ideally be carried out before the evolution of brain infarction and secondary brain damage. 5 There are many issues that need to be clarified including the size of craniotomy (particularly when the fontanels are not fused), also material and timing of craniolpasty in these patients. In summary, it has been shown that despite severe brain damage, 5 early removal of bone flap reduction in intracranial pressure and fewer episodes of intracranial hypertension occur resulting in good functional outcome and improved quality of life in children.…”

“…5 There are many issues that need to be clarified including the size of craniotomy (particularly when the fontanels are not fused), also material and timing of craniolpasty in these patients. In summary, it has been shown that despite severe brain damage, 5 early removal of bone flap reduction in intracranial pressure and fewer episodes of intracranial hypertension occur resulting in good functional outcome and improved quality of life in children. 4 However there is a need for further controlled trials to evaluate the indication and standardization of early decompressive craniectomy in pediatric severe head injury.…”